Healthcare Provider Details

I. General information

NPI: 1639251937
Provider Name (Legal Business Name): SOUTHAMPTON OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 FAIRVIEW DR SUITE H
FRANKLIN VA
23851-1226
US

IV. Provider business mailing address

102 FAIRVIEW DR SUITE H
FRANKLIN VA
23851-1226
US

V. Phone/Fax

Practice location:
  • Phone: 757-569-9898
  • Fax: 757-569-9597
Mailing address:
  • Phone: 757-569-9898
  • Fax: 757-569-9597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101002217
License Number StateVA

VIII. Authorized Official

Name: MRS. DIANE D ROMANO
Title or Position: OWNER
Credential:
Phone: 757-569-9898